The Microvascular Health Status Predicts Radio-Induced Acute Toxicities in Breast, Prostate and Head and Neck Cancer Patients

PURPOSE/OBJECTIVE(S)

investigate the role of healthy/unhealthy microcirculation in predicting acute toxicity (tox) after breast (BC), prostate (PC) and Head & Neck (HNC) cancer RT.

MATERIALS/METHODS

We enrolled BC patients (pts) treated with hypofractionated-RT after conservative surgery (42.4 Gy + 10 Gy boost to tumor bed), PC pts receiving radical-RT (65 Gy / 25 fractions), HNC pts treated with conventional RT (54-70 Gy @ 1.8-2 Gy/fr) or moderately hypofractionation (56.1-69.96 Gy @ 1.7-2.12 Gy/fr). We assessed baseline sublingual-microvasculature (MV) health status before RT using a sidestream dark-field camera coupled to the GlycoCheck™ software. The system records videos showing the live movement of red blood cells (RBCs) in the microvessels. It computes 5 functional parameters: (a) perfused boundary region (PBR) estimating the penetration of RBCs into the permeable part of the endothelial glycocalyx (higher PBR values result from damaged glycocalyx, indicating impaired microcirculation); (b) density of capillaries (1/mm2); (c) blood flow in the recorded area (103 μm3/s/mm2); (d) recruitment capacity (quantifying the ability to recruit additional capillaries); (e) a global MV_HealthScore (MVHS), higher values indicate healthier MV. MVHS is computed by weighting information from the previous parameters. The computation of MVHS needs a prolonged video acquisition not reached by less compliant patients. Endpoint for this analysis was acute tox. We selected a clinically relevant tox endpoint for each cancer site: grade≥2 erythema (G2+E) for BC, any grade≥3 tox (G3Tox) for HNC and persistent grade≥1 tox simultaneously present in gastrointestinal and genitourinary domains (G1+GIGU) for PC. We used logistic regression to assess MV functional parameters' association with toxicity.

RESULTS

We evaluated 63 BC, 38 PC, 39 HNC pts. 77 (55%) had an evaluation for MVHS. 23/63 BC pts presented with G2+E, 12/38 PC pts with G1+GIGU, 12/39 HNC pts with G3Tox. Average MVHS was 3.6, 3.2, 2.7 in BC, HNC and PC, respectively (P>0.15). The MVHS associated with tox: healthy MV protects from tox (continuous, OR = 0.66 for 1 point increase, p = 0.01, AUC 0.69). Categorizing pts as low MVHS (<2.5), average MVHS (2.5-6.5) and high MVHA (>6.5), the observed toxicity rates in the 3 classes were 50%, 26%, 0% (p = 0.02). Also, a 3-variate model including the separated functional parameters predicted tox (AUC 0.67) on the 144 pts: higher PBR is a risk (OR = 7.6), higher capillary density protects (Logarithm, OR 0.002), higher blood flow is a risk (Logarithm, OR = 14.2).

CONCLUSION

These data suggest an interaction of compromised MV with repair mechanisms. The MVHS model predicts acute toxicity in BC/PC/HN pts proving (i) a quantitative relationship between MV state and radio-susceptibility and (ii) in an organ-agnostic way. The systemic functional information derived by the sublingual microscope could boost the personalization of predictive models and tailor them to the single-patient functional status. Funded by AIRC IG 21479.

A multicenter LArge retrospectIve daTabase on the personalization of Stereotactic ABlative Radiotherapy use in lung metastases from colon-rectal cancer: the LaIT-SABR study

INTRODUCTION

stereotactic ablative radiotherapy (SABR) has been shown to increase survival in oligometastatic disease, but local control of colorectal metastases remains poor. We aimed to identify potential predictive factors of SBRT response through a multicenter large retrospective database and to investigate the progression to the polymetastatic disease (PMD).

MATERIAL AND METHODS

the study involved 23 centers, and was approved by the Ethical Committee (Prot. Negrar 2019-ZT). 1033 lung metastases were reported. Clinical and biological parameters were evaluated as predictive for local progression-free survival (FLP). Secondary end-point was the time to the polymetastatic conversion (tPMC).

RESULTS

Two-year FLP was 75.4%. Two-year FLP for lesions treated with a BED <100 Gy, 100-124 Gy, and ≥125 Gy was 76.1%, 70.6%, and 94% (p=0.000). Two-year FLP for lesion measuring ≤10 mm, 10-20 mm, and >20 mm was 79.7%, 77.1%, and 66.6% (p=0.027). At the multivariate analysis a BED ≥125 Gy significantly reduced the risk of local progression (HR 0.24, 95%CI 0.11-0.51; p=0.000). Median tPMC was 26.8 months. Lesions treated with BED ≥125 Gy reported a significantly longer tPMC as compared to lower BED. The median tPMC for patients treated to 1, 2-3 or 4-5 simultaneous oligometastases was 28.5, 25.4, and 9.8 months (p=0.035).

CONCLUSION

The present is the largest series of lung colorectal metastases treated with SABR. The results support the use of SBRT in lung oligometastatic colorectal cancer patients as it might delay the transition to PMD or offer relatively long disease-free period in selected cases. Predictive factors were identified for treatment personalization.

Trade-Offs with rehabilitation Effectiveness (REs) and Efficiency (REy) in a sample of Italian disabled persons in a in post-acuity rehabilitation unit

BACKGROUND

Intensive Rehabilitation Centres, known in Italy as "code 56", admit patients who need to recover from an acute episode. Different Rehabilitation Impact Indices have been proposed as composite rehabilitation outcomes measuring the rate of improvement due to a rehabilitation program. The most widely employed measure the performance of Activities of daily living in rehabilitation is the modified Barthel Index. The Barthel Index-based Rehabilitation Impact Indices are the Rehabilitation Effectiveness and the Rehabilitation Efficiency.

AIM

The aim of our study was to evaluate the trade-off between Rehabilitation Effectiveness tayand Rehabilitation Efficiency with respect to the Barthel Index admission score and the Length Of Stay, and their ideal ranges that optimized both indices.

METHODS

We retrospectively evaluated data of all patients admitted to intensive rehabilitation unit of the Scientific Institute for Research and Healthcare San Raffaele Pisana of Rome, from January 2006 to March 2018. The primary outcome measures of our study were patient's Rehabilitation Effectiveness and Rehabilitation Efficiency during the hospital stay.

RESULTS

A database of 3,466 patients was analysed and the Rehabilitation Effectiveness and Rehabilitation Efficiency indexes were calculated. We calculated the median rank ratio of the Rehabilitation Effectiveness to the Rehabilitation Efficiency against Barthel Index scores. We calculated the median rank ratio of the Rehabilitation Effectiveness to Rehabilitation Efficiency against Barthel Index scores and days of stay. The median rank ratio of the Rehabilitation Effectiveness to the Rehabilitation Efficiency value were 1 in the range of Barthel Index scores from 32 to 42. The median rank ratio of the Rehabilitation Effectiveness to Rehabilitation Efficiency value were 1 for a Length of Stay corresponding to 33 days.

CONCLUSIONS

In our study we calculated the Trade-offs between Rehabilitation Effectiveness and Rehabilitation Efficiency with respect to admission Barthel Index Score and Length Of Stay in a population of 3,466 patients affected by orthopedic (1,707) and neurological (1,759) diseases. Every member of the healthcare team should be aware of such trade-offs when they make decisions about rehabilitation services.

N6L pseudopeptide interferes with nucleophosmin protein-protein interactions and sensitizes leukemic cells to chemotherapy

NPM1 is a multifunctional nucleolar protein implicated in several processes such as ribosome maturation and export, DNA damage response and apoptotic response to stress stimuli. The NPM1 gene is involved in human tumorigenesis and is found mutated in one third of acute myeloid leukemia patients, leading to the aberrant cytoplasmic localization of NPM1. Recent studies indicated that the N6L multivalent pseudopeptide, a synthetic ligand of cell-surface nucleolin, is also able to bind NPM1 with high affinity. N6L inhibits cell growth with different mechanisms and represents a good candidate as a novel anticancer drug for a number of malignancies of different histological origin. In this study we investigated whether N6L treatment could drive antitumor effect in acute myeloid leukemia cell lines. We found that N6L binds NPM1 at the N-terminal domain, co-localizes with cytoplasmic, mutated NPM1, and interferes with its protein-protein associations. N6L toxicity appears to be p53 dependent but interestingly, the leukemic cell line harbouring the mutated form of NPM1 is more resistant to treatment, suggesting that NPM1 cytoplasmic delocalization confers protection from p53 activation. Moreover, we show that N6L sensitizes AML cells to doxorubicin and cytarabine treatment. These studies suggest that N6L may be a promising option in combination therapies for acute myeloid leukemia treatment.

Structural investigation of nucleophosmin interaction with the tumor suppressor Fbw7γ

Nucleophosmin (NPM1) is a multifunctional nucleolar protein implicated in ribogenesis, centrosome duplication, cell cycle control, regulation of DNA repair and apoptotic response to stress stimuli. The majority of these functions are played through the interactions with a variety of protein partners. NPM1 is frequently overexpressed in solid tumors of different histological origin. Furthermore NPM1 is the most frequently mutated protein in acute myeloid leukemia (AML) patients. Mutations map to the C-terminal domain and lead to the aberrant and stable localization of the protein in the cytoplasm of leukemic blasts. Among NPM1 protein partners, a pivotal role is played by the tumor suppressor Fbw7γ, an E3-ubiquitin ligase that degrades oncoproteins like c-MYC, cyclin E, Notch and c-jun. In AML with NPM1 mutations, Fbw7γ is degraded following its abnormal cytosolic delocalization by mutated NPM1. This mechanism also applies to other tumor suppressors and it has been suggested that it may play a key role in leukemogenesis. Here we analyse the interaction between NPM1 and Fbw7γ, by identifying the protein surfaces implicated in recognition and key aminoacids involved. Based on the results of computational methods, we propose a structural model for the interaction, which is substantiated by experimental findings on several site-directed mutants. We also extend the analysis to two other NPM1 partners (HIV Tat and CENP-W) and conclude that NPM1 uses the same molecular surface as a platform for recognizing different protein partners. We suggest that this region of NPM1 may be targeted for cancer treatment.

Robot-assisted gait training versus treadmill training in patients with Parkinson's disease: a kinematic evaluation with gait profile score

The purpose of this study was to quantitatively compare the effects, on walking performance, of end-effector robotic rehabilitation locomotor training versus intensive training with a treadmill in Parkinson's disease (PD). Fifty patients with PD were randomly divided into two groups: 25 were assigned to the robot-assisted therapy group (RG) and 25 to the intensive treadmill therapy group (IG). They were evaluated with clinical examination and 3D quantitative gait analysis [gait profile score (GPS) and its constituent gait variable scores (GVSs) were calculated from gait analysis data] at the beginning (T0) and at the end (T1) of the treatment. In the RG no differences were found in the GPS, but there were significant improvements in some GVSs (Pelvic Obl and Hip Ab-Add). The IG showed no statistically significant changes in either GPS or GVSs. The end-effector robotic rehabilitation locomotor training improved gait kinematics and seems to be effective for rehabilitation in patients with mild PD.

A proposal for an Italian minimum data set assessment protocol for robot-assisted rehabilitation: a Delphi study

BACKGROUND

At present there is no agreement on a common evaluation protocol to assess improvement in stroke patients after robotic therapy.

AIM

The aim of this study was to identify a Minimum Data Set Assessment Protocol, using an agreement-based survey.

DESIGN

A Delphi survey.

SETTING

This study was conceived by the Italian Robotic Neurorehabilitation Research Group (IRNRG), an Italian group involved in the clinical application of robot-assisted rehabilitation devices

POPULATION

Stroke subjects.

METHODS

A 3-round Delphi survey was carried out through the electronic submission of questionnaires to a panel of experts identified in fourteen rehabilitation centers. For each generated item, experts were asked to rate questions on a 5 point Likert Scale.

RESULTS

After the 1st round the questionnaire was filled out by 43 (84.3%) out of 51 experts invited to participate in the study. In the 2nd and 3rd rounds we explored the specific evaluation tools for each of the ICF domains identified in the 1st round. The experts identified the following assessment tools for the upper limb: the Ashworth Scale, the Fugl-Meyer assessment scale, the Frenchay Arm Test, the Medical Research Council scale, the Motricity Index, Frenchay Activities Index and Modified Barthel Index; and for the lower limb: the Ashworth Scale, the Motricity Index, the 10 meter walking Test, the 6 minutes walking Test, the Functional Ambulatory Classification, the Timed Up and Go Test, the Walking Handicap Scale, the Borg Rating of Perceived Exertion, the Heart Rate, the Medical Research Council Scale, the Tinetti Balance Scale and the Modified Barthel Index.

CONCLUSION

The Delphi survey presented in this study allows the identification of a shared assessment protocol to be applied in clinical practice and research for the evaluation of the real improvement related to robot-assisted rehabilitation of the upper and lower limb in patients after stroke.

CLINICAL REHABILITATION IMPACT

Clinicians and researchers could use the results of this study to obtain a common language in robotic rehabilitation assessments.

Management of stroke patients submitted to botulinum toxin type A therapy: a Delphi survey of an Italian expert panel of specialist injectors

BACKGROUND

Spasticity is a common disabling symptom of several neurological conditions including stroke. Botulinum toxin type A (BTX-A) injection represents the gold standard therapy for focal spasticity. Post-stroke management of patients receiving BTX-A therapy has been variously investigated, but general agreement on how and when to implement rehabilitation is lacking.

AIM

To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapy for the focal treatment of spasticity.

DESIGN

The study employed the Delphi technique through the COSMO project (Consensus on Post-Injection Management in Post-stroke Spasticity).

METHODS

Italian neurologists and physiatrists with experience in BTX-A therapy were selected to participate in the survey. Their anonymous opinions on key issues in treatment strategies in post-stroke spasticity were collected in three sequential rounds facilitated by a web platform. Consensus on a given issue was defined as agreed opinion by at least 66% of the survey participants.

RESULTS

In all, 44 Italian experts were involved. Positive consensus was reached on the need to start rehabilitation during the first week after BTX-A injection therapy, with a rehabilitation program comprising both stretching combined with electrical stimulation and exercise therapy. Functional surgery may be considered only after 12-24 months in cases of BTX-A therapy failure. The use of commercial or custom-made orthoses in selected cases was recommended. The appropriate time interval between two BTX-A injections is 3-6 months, and clinical assessment should be performed 1 month after injection.

CONCLUSION

The results of this national survey confirm that clinical experts on the use of BTX-A therapy for spasticity after stroke agree on the need to initiate rehabilitation treatment immediately after BTX-A injection: muscle stretching exercises, eventually combined with neuromuscular electrical stimulation, may enhance the effect of BTX-A therapy. Outcome after BTX-A therapy should be assessed at repeated follow-up visits.

CLINICAL REHABILITATION IMPACT

This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy.

The relation between Parkinson's disease and ageing. Comparison of the gait patterns of young Parkinson's disease subjects with healthy elderly subjects

BACKGROUND

The gait of healthy elderly and of subjects with Parkinson's disease (PD) displays some common features, suggesting that PD may be a model of ageing.

AIM

The aim of the study was to quantify highlight the differences and similarities between the gait patterns of young PD and healthy elderly, to uncover if PD could be assumed as a model of ageing.

DESIGN

An optoelectronic system was used for 3D gait analysis evaluation.

POPULATION AND METHODS

We compared the gait parameters of 15 young PD (YPD) with the gait of 32 healthy elderly subjects (ES) and 21 healthy subjects age-matched with the PD subjects. RESULTS. Common features between YPD and ES were majorly found in the parameters that reflect the presence of an unstable, uncertain gait, and of corrective strategies employed to reduce instability. On the other side, typical features were present in the gait patterns of PD subjects. CONCLUSION. Our study helped identifying some typical characteristics of the onset disease, and to unravel the symptoms of ageing from those of PD by comparing young PD subjects to elderly healthy subjects.

CLINICAL REHABILITATION IMPACT

This allows a deeper understanding of the mechanisms underlying the gait in ageing and PD.

Management of shoulder periprosthetic fractures: our institutional experience and review of the literature

Fractures of the humerus in patients with total shoulder replacement are rare and difficult to treat. The treatment of periprosthetic humeral fractures depends on the location of the fracture in relation to the humeral stem and the stability of the stem/bone interface. We wished to determine the treatment outcomes in a series of patients managed in our institution with periprosthetic humeral fractures. We also carried out a review of the literature. Over a 5 year period, out of 10 patients, 7 were available at the final follow up with a mean age of 72 years (range 68-75). A fall from standing height was the most common mechanism of injury. All patients were found to have stable prosthesis in situ and were treated with angular stable plates and cerclage wiring. The mean time from the total shoulder replacement to injury (fracture) was 11.2 months (range 8-21). All fractures united without complications at a mean time of 5.1 months (range 4-6). The literature review revealed a limited number of publications reporting on the management of approximately 40 patients. The outcome noted in these patients is also presented.

Action observation and mirror neuron network: a tool for motor stroke rehabilitation

Mirror neurons are a specific class of neurons that are activated and discharge both during observation of the same or similar motor act performed by another individual and during the execution of a motor act. Different studies based on non invasive neuroelectrophysiological assessment or functional brain imaging techniques have demonstrated the presence of the mirror neuron and their mechanism in humans. Various authors have demonstrated that in the human these networks are activated when individuals learn motor actions via execution (as in traditional motor learning), imitation, observation (as in observational learning) and motor imagery. Activation of these brain areas (inferior parietal lobe and the ventral premotor cortex, as well as the caudal part of the inferior frontal gyrus [IFG]) following observation or motor imagery may thereby facilitate subsequent movement execution by directly matching the observed or imagined action to the internal simulation of that action. It is therefore believed that this multi-sensory action-observation system enables individuals to (re) learn impaired motor functions through the activation of these internal action-related representations. In humans, the mirror mechanism is also located in various brain segment: in Broca's area, which is involved in language processing and speech production and not only in centres that mediate voluntary movement, but also in cortical areas that mediate visceromotor emotion-related behaviours. On basis of this finding, during the last 10 years various studies were carry out regarding the clinical use of action observation for motor rehabilitation of sub-acute and chronic stroke patients.

Use of the robot assisted gait therapy in rehabilitation of patients with stroke and spinal cord injury

Difficulty in walking is a major feature of neurological disease, and loss of mobility is the activity of daily living on which patients place the greatest value. The impact on patients is enormous, with negative ramifications on their participation in social, vocational, and recreational activities. In current clinical practice the gait restoration with robotic device is an integral part of rehabilitation program. Robot therapy involves the use of a robot exoskeleton device or end-effector device to help the patient retrain motor coordination by performing well-focused and carefully directed repetitive practice. The exoskeleton, as an assistive device, is also an external structural mechanism with joints and links corresponding to those of the human body. These robots use joint trajectories of the entire gait cycle and offer a uniform (more or less) stiff control along this trajectory. In this field the new powered exoskeleton ReWalk (Argo Medical Technologies Ltd) was developed to have an alternative mobility solution to the wheelchair and rehabilitation treatment for individuals with severe walking impairments, enabling them to stand, walk, ascend/descent stairs and more. The end-effector-based robot is a device with footplates placed on a double crank and rocker gear system. Alternatives to powered exoskeletons are devices that use movable footplates to which the patient's feet are attached. All devices include some form of body weight support. Prominent goals in the field include: developing implementable technologies that can be easily used by patients, therapists, and clinicians; enhancing the efficacy of clinician's therapies and increasing the ease of activities in the daily lives of patients.

Cartilaginous metaplasia of varicose veins: a case report

Cartilaginous metaplasia of superficial veins was found in a 64-year-old woman who underwent surgery for varicose veins. At operation, some varicose veins of the medial thigh were semi-rigid and fibroelastic to the touch. Histology revealed that half the lumen was occupied by chondroid tissue. The other half was obliterated by fibrous tissue, typical of post-thrombotic involution. Possible causes of cartilaginous metaplasia are briefly discussed.

Sport, free time and hobbies in people with spinal cord injury

STUDY DESIGN

Prospective, multicenter follow-up (F-U) observational study.

OBJECTIVES

To investigate the changes in participation and sports practice of people after spinal cord injury (SCI) and their impact on perceived quality of life (QoL).

METHODS

The questionnaire investigated the health status and management of clinical conditions and attendance of social integration, occupation, autonomy, car driving, sentimental relationships and perceived QoL in a SCI population 4 years after the first rehabilitation hospitalization.

RESULTS

Respondents were 403, 83.4% male; 39% was tetraplegic. At F-U, 42.1% worked and studied, 42.2% still held their jobs or studies, and 69% drove the car. In all, 77.2% had bowel continence and 40.4% urinary continence. The results showed that for the 68.2% of respondents, the attendance of friends, relatives and colleagues during their free time was the same or increased compared with the time before the injury, whereas 31.8% showed a decrease. The amount of time the 52.1% of respondents left home was the same or increased compared with before the trauma, whereas 50.6% of the respondents said that the time they were engaged in hobbies was either the same or increased.

CONCLUSION

SCI people who perceived their QoL as being higher, and whose attendance, autonomy and time was increased in respect to hobbies, were mainly men with an age range between 36 and 40 years, unmarried, paraplegic and with A-B Asia Score. Regarding the amount of time dedicated to practicing sports, the only difference was the most of that respondents, who indicated a decrease, were women.

Docetaxel, cisplatin and 5-fluorouracil-based induction chemotherapy followed by intensity-modulated radiotherapy concurrent with cisplatin in locally advanced EBV-related nasopharyngeal cancer

BACKGROUND

This monocentric study evaluates the activity and tolerability of docetaxel (Taxotere), cisplatin and 5-fluorouracil (5-FU) (TPF) induction chemotherapy followed by intensity-modulated radiotherapy (IMRT) concurrent with high-dose cisplatin in Epstein-Barr virus -related locally advanced undifferentiated nasopharyngeal cancer.

PATIENTS AND METHODS

We retrospectively reviewed the records of patients who received induction docetaxel 75 mg/m(2) and cisplatin 75 mg/m(2) on day 1, and 5-FU 750 mg/m(2)/day (96-h continuous infusion). Following induction, patients received full doses of IMRT concurrently with cisplatin 100 mg/m(2) every 21 days for three cycles.

RESULTS

Thirty patients received three TPF cycles (median). Induction was well tolerated; the main toxicity was neutropenia (33%, grade 3-4). During chemoradiotherapy, neutropenia (40%) and mucositis (43%) were the most frequent grade 3-4 adverse events. Mean dose of IMRT was 68.8 Gy. Worst late toxicity was xerostomia. Complete response rate was 93%. At 35 months, two patients had locoregional recurrence, three had distant metastases, and one had both. Three-year progression-free survival and overall survival were 79% [95% confidence interval (CI) 64% to 94%] and 87% (95% CI 74%- to 100%), respectively.

CONCLUSIONS

In this high-stage nonendemic cancer population, TPF followed by high-dose cisplatin IMRT was promising; this treatment approach deserves evaluation in randomized trials.

Mirror neurons: action observation treatment as a tool in stroke rehabilitation

BACKGROUND

The observation of actions performed by others activate in an observer the same neural structures (including mirror neurons) as when he/she actually performs the same actions.

AIM

The aim of the present study was to assess whether action observation treatment may improve upper limb motor impairment in chronic stroke patients.

DESIGN

This was an observational study.

SETTING

Patients were recruited by three Italian Centres for Neurorehabilitation between 2006 and 2008.

POPULATION

Twenty-eight chronic stroke patients with upper limb impairment have undergone for four weeks, five days a week, a rehabilitation treatment based on observation of video-clips presenting hand daily actions, followed by the imitation of those same actions with the affected limb.

METHODS

Functional evaluation by means of Modified Barthel Index (MBI), Frenchay Arm Test (FAT) and Fugl Meyer (FM) was carried out twice before treatment (BT1 and BT2), at an interval of 15 days, then after treatment (AT1) and finally at a two-month follow-up (AT2). Wilcoxon Signed Rank test was applied to test differences between scores obtained from functional scales before and after treatment (BT1 vs. BT2; BT2 vs. AT1; AT1 vs. AT2).

RESULTS

In all scales, scores did not differ when comparing BT1 with BT2. Scores improved significantly in all scales at AT1 as compared to BT2 (MBI, P=0.026; FAT, P=0.005; FM, P=0.001). This improvement was still present at the two-month follow-up as testified by no score difference between AT1 and AT2.

CONCLUSION

Action Observation Treatment may become a useful strategy in the rehabilitation of stroke patients.

CLINICAL REHABILITATION IMPACT

The present preliminary study suggests that stimulation of neural structures (including mirror neurons), activated when the patients actually perform the same actions as those observed could constitute a good alternative rehabilitative approach in chronic stroke patients.

Rehabilitation in patients affected by different types of stroke. A one-year follow-up study

AIM

Stroke is the third highest cause of death and the leading cause of chronic disability in adults in Italy. More than half of patients who survive the first month after a stroke will require specialised rehabilitation. Rehabilitation is, however, an expensive and limited resource, and its success depends on careful selection of patients. The aim of this study was to identify the functional ability at discharge and after one-year of follow-up in a large sample of first-time stroke patients from a rehabilitation hospital according to the stroke Oxfordshire Community Stroke Project (OCSP) criteria.

METHODS

A multicenter observational study was conducted among 1023 first-time stroke patients who were admitted to 18 different Italian inpatient rehabilitation centres between February 1999 and November 2000. The study population consisted of 946 (92.4%) of the 1023 enrolled at baseline. Each patient has been first evaluated within 72 h after admission and, on a second occasion, within 72 h before discharge. From the 722 ischemic strokes evaluated at baseline, after one-year of follow-up 76 participants died. From the survived 646 patients, we had 513 (79.0%) participants both evaluated at baseline and after one-year of follow-up. Clinical data regarding stroke type and ischemic stroke clinical syndrome, according to the Oxfordshire Community Stroke Project (OCSP) criteria; the degree of impairment, both motor (assessed by Barthel Index [BI], Motricity Index, and Trunk Control Test) and neuropsychological (assessed by the Mini Mental State Examination, and the presence of aphasia or neglect); the extent of disability, as assessed by Functional Independence Scale (FIM) and the evidence of concomitant prespecified medical complications, as well as of dysphasia and of the need of indwelling urinary catheter. Other variables were taken into account, such as the time interval between stroke onset and admission to rehabilitation ward and the length of stay. To assess stroke outcome, two different indexes were selected: the frequency of home discharge and the extent of functional recovery.

RESULTS

There were 722 (76.3%) ischemic and 224 (23.7%) hemorrhagic strokes. Among ischemic strokes, the partial anterior circulation infarct was the most frequent syndrome, accounting for the 33.2% of cases. The posterior circulation infarct syndrome was the less frequent (14.1%). Lacunar anterior circulation infarct was present for the 29.5% and finally, the total anterior circulation infarct (TACI) was present for the 23.2%. According to the OCSP criteria, the TACI syndrome received 76.1±52.9 (mean±SD) days of rehabilitation, which were statistically different from the other three types of stroke. At discharge, the BI and the FIM of patients affected by TACI was significantly lower and higher, respectively, from the other three type of stroke. However, this difference disappear after one-year of follow-up.

CONCLUSION

The TACI subtype of stroke required higher days of rehabilitation from the other type of stroke according to the OCSP criteria. Rehabilitation program is efficacious for improving functional ability of patients affected by stroke although the program should be tailored according to the stroke type.

[Occupational therapy and return to work of the people with traumatic spinal cord injury (TSCI)]

The aim of this study was to evaluate the employment condition of persons with TSCI 4 years after discharge from rehabilitation facilities, as well as the factors related to better outcome. In the follow-up we interviewed 403 persons. We recorded the following variables: current employment status, causes of unemployment and their correlation with demographic status, clinical status and other information. In our results 51.4% of the interviewed persons were unemployed, 34.7% had a job and 7.2% were students. Among the unemployed persons 34% had suffered an accident at work, 31% had been unable to find suitable work and 31% were retired. Employment significantly correlated with younger age, single status, being paraplegic, being autonomous in bladder/bowel management, driving a car and a better quality of life. In the multivariate analysis the factors predicting better outcome were younger age, ability to drive and a better quality of life.

Is health-related-quality of life of stroke patients influenced by neurological impairments at one year after stroke?

AIM

The aim of this study was to evaluate which neurological impairments on discharge from rehabilitation services are associated with a worse outcome in terms of health related-quality of life (HRQoL) one year after stroke.

METHODS

We enrolled 528 first-time stroke patients in a multicenter observational study involving 18 Italian inpatients rehabilitation centers. Neurological impairment-related factors, socio-demographic and general clinical variables and process indicators were considered independent variables at discharge. Outcome was represented by the following dependent variables of HRQoL: EuroQoL-5D questionnaire (5D-EQoL) and its derived index (Eq-Index) and a Visual Analogue Score (QoL-VAS).

RESULTS

The strongest predictors of lower HRQoL were an incomplete limbs motor recovery. An incomplete lower limb motor recovery was associated with a lower HRQoL only in the "mobility" domains, whereas a incomplete upper limb motor recovery could predict a lower HRQoL in all domains except "mobility". Regarding cognitive impairments, the presence of neglect at discharge was associated with a lower HRQoL in "self-care", "pain-discomfort" and "anxiety-depression". Female gender, presence of urinary catheter seemed to exert a much lesser role in predicting HRQoL.

CONCLUSION

The results of this study suggest that upper limb motor impairments may have a detrimental impact on the patient's perceived HRQoL one year after stroke.

TPF induction chemotherapy (CT) followed by concomitant cisplatin/radiotherapy (cCTRT) in locally advanced nasopharyngeal cancer (LANPC)

6046

Background: Recent meta-analysis showed better event free survival in LANPC with induction CT. In head and neck cancer, docetaxel, cisplatin and 5 FU (TPF) induction chemotherapy led to survival gain over cisplatin and 5FU alone. We studied feasibility and activity of TPF induction CT followed by cCTRT in LANPC. Methods: From October 2004 to May 2008, 45 pts with LANPC were treated at our Institution with 2 to 4 cycles (median 3) of induction TPF (docetaxel 75 mg/sm and cisplatin 75 mg/sm on day 1, and 5-FU 750 mg/sm/day ci for 96 hrs. Prophylactic ciprofloxacin was administered for 10 days each cycle, while use of G-CSF was not allowed. Following CT, pts received full doses radiotherapy (RT) concurrent with cisplatin 100 mg/sm q 21 days. Intensity modulated radiotherapy (IMRT) was delivered to 34 pts (76%). All but two pts had non-keratinizing carcinoma. Stage IV pts were 60%, stage III 34%, and 6% stage II. T4 was present in 24% and N3 disease was diagnosed in 42% of the pts. Results: TPF was well tolerated, with main toxicity consisting in neutropenia (31% G3–4). Response rate was 87%. RT dose ranged from 64 Gy to 70 Gy (median 70 Gy). Main toxicities during cCTRT were: neutropenia (38% G3, 4% G4), febrile neutropenia (11% G3), thrombocytopenia (7% G3–4) and mucositis (40% G3, 4% G4). Nasogastric tube was placed in 33% of pts and maintained for a median of 40 days. During cCTRT, platinum compounds mean dose delivery was 75%, with 6 pts shifting to carboplatin for renal function impairment. Observed late toxicities were xerostomia (G3 in 38% of cases) and peripheral neurotoxicity (G1 in 27%, G2 in 7% and G3 in 2% of the pts). After treatment completion, complete and partial response were recorded in 78% and 20% of the pts respectively, while 1 pt showed stable disease. With a median follow up of 22 months (range 7 to 47), 9 pts showed recurrence or progressive disease (7 at local and/or regional level, 2 distant metastases and 1 at both sites), with a 2-years event free survival of 78% and an overall survival of 85%. Conclusions: TPF followed by cCTRT is feasible in LANPC. In this high-stage nonendemic population local-regional disease control still remains the main therapeutic goal. Supported in part by AIRC.

[Table: see text]

Developing a minimum data set for stroke patients assessment: the " Protocollo di Minima per l'Ictus (PMIC) as a starting point towards an Italian stroke registry

AIM

The complex nature of stroke sequelae requires several assessment instruments to quantify correctly every residual symptom. As there was no general consensus on stroke evaluation among Italian Physiatrists, in 2004 the Italian Society of Physical Medicine and Rehabilitation and S. Lucia Foundation (a Scientific Institute for hospitalization and treatment) established a Project Group to propose a standardized assessment tool (''Protocollo di Minima per l'Ictus PMIC'') for acute, post-acute and community-living stroke patients. This tool aimed to be easy to use and comprehensive of all the elements necessary for accurately address the great range of different rehabilitation needs. The objective was to provide physiatrists with a standard assessment battery and to make prognostic factors available on large community samples.

METHODS

From end 2004 to early 2006, the Project Group examined literature data on stroke assessment, prognostic factors and outcome and selected the specific data elements to be included in a data collection tool.

RESULTS

A consensus was reached on a ''minimum'' core set of data. This protocol was peer submitted in early 2006, to test the burden of data collection, and to allow modifications and adjustments. Specific forms (file to download) for data collection and database to be shared (a dedicated ''Client'' software) are now freely offered by the Project Group for data collection.

CONCLUSION

PMIC is an evaluation procedure manageable in every-day practice and in every setting, a quick screening instrument that, given its large diffusion, can be expanded from a National Database into a National Rehabilitation Stroke Registry.

Exploring the use of ''Protocollo di Minima per l'ictus - PMIC'': preliminary data in two Italian rehabilitation units

AIM

This study was designed associated to evaluate applicability of ''Protocollo di Minima per l'ictus PMIC'' in Italian rehabilitative units, and to collect preliminary data

METHODS

The authors evaluated, by means of PMIC, stroke patients admitted to rehabilitative unit of both IRCCS Santa Lucia Foundation, Rome and Sant'Agostino Estense New Civil Hospital, Baggiovara, Modena for sequelae of their first-ever event. Multiple regression analyses (backward selection) were then performed to identify variables with discharge functional status (Barthel Index [BI] and Functional Ambulation Category [FAC] score) and rehabilitation effectiveness (on BI and FAC), and logistic regression to quantify the probability of reaching a discharge BI score > or = 70 and FAC score > or = 4.

RESULTS

Sample included 94 patients with recent stroke (onset-admission interval 12.68+/-16.09 days). Mean time of evaluation for each case was 16.15+/-1.43 minutes. Increasing age, sex, degree of basal impairment and disability confirmed to be reliable prognostic factors.

CONCLUSION

Recording data of patients admitted to rehabilitative hospital according to PMIC, is easy, quick and enough exhaustive.

Outcome predictors of rehabilitation for first stroke in the elderly

AIM

The prediction of stroke outcome in the elderly can be rather difficult, due to the potential interference into disability and handicap development of several clinical modifiers, such as comorbidity, medical complications, neuropsychological impairment proper to the aging brain and social issues. These factors can strongly affect old patient response to rehabilitation and need to be taken into account, along with ageing per se, to optimize health resource efficiency for the care of disability due to stroke. In this study, we tried to identify outcome determinants of stroke rehabilitation specific for the elderly.

METHODS

A total of 359 first-stroke patients aged 75 years, admitted for active rehabilitation treatment to hospital rehabilitation wards, were enrolled into a multicenter cohort (prospective) study. They all underwent a comprehensive medical rehabilitation program. We considered as primary outcomes the frequency of home discharge and the extent of functional recovery, assessed by Functional Independence Scale (FIM) and expressed as the Montebello Rehabilitation Factor Score (MRFS) efficacy. Each measure of outcome was related to age, as well as other potential clinical and functional confounders, according to a multivariate model. For each dependent variable, two models were developed, using either FIM total score or FIM domains scores at admission among predictors.

RESULTS

FIM total score increased from 55.8+/-24 to 75.3+/-30 (P<0.0001), with a mean MRFS efficacy of 0.33+/-0.25. Most patients (79.9%) were discharged home. Age turned out as independently and inversely related to MRFS, explaining at the most 3.6% of its variance, although FIM at admission was its most powerful predictor. Home discharge was not related to age, but to social issues, such as living in family before admission, and cognition.

CONCLUSION

The present study suggests that rehabilitation can be effective in elderly stroke patients, in improving function as well as in favorably affecting discharge destination. In fact, age per se predicts the outcome at a lesser extent than other clinical covariates, such as functional and cognitive status at admission and social situation.

The nature of skin pigmentations in chronic venous insufficiency: a preliminary report

BACKGROUND

Chronic Venous Insufficiency (CVI) provokes skin pigmentation commonly seen in the gaiter region of the leg. The exact nature and pathogenesis of this are poorly understood.

OBJECTIVE

To evaluate the presence of melanin and haemosiderin in histological sections of the skin of limbs with primary varicose veins.

METHODS

Histological investigations were performed in 49 biopsies from pigmented and non-pigmented skin of limbs with varicose veins and control limbs.

RESULTS

All samples from pigmented skin showed a higher content of melanin than controls. In contrast, haemosiderin was found in only a few biopsies taken from the more severely pigmented skin in areas of lipodermatosclerosis. Erythrocyte diapedesis was observed only where an intense inflammatory process was also present.

CONCLUSIONS

Our findings suggest that in the initial phases of skin changes due to venous disease, pigmentation is attributable to melanin. Haemosiderin seems to play a role in the evolution of skin changes toward lipodermatosclerosis and ulceration. Erythrocyte diapedesis is likely to occur only during acute phases of the inflammatory process. Further investigations are needed to explain the cause and the exact cellular and molecular mechanisms responsible for hypermelanisation occurring in early phases of skin changes in CVI.

Post-detection nonlinear distortion for efficient MLSD in optical links

In this paper, we investigate the use of nonlinear distortion of the electrical post-detection signal in order to design simple, yet very effective, maximum likelihood sequence detection (MLSD) receivers for optical communications with direct photo-detection. This distortion enables the use of standard Euclidean branch metrics in the Viterbi algorithm which implements MLSD. Our results suggest that the nonlinear characteristic can be optimized with respect to the uncompensated chromatic dispersion and other relevant system parameters, such as the extinction ratio. The proposed schemes with optimized distortion exhibit the same performance of more sophisticated MLSD schemes, still guaranteeing more efficient Viterbi algorithm implementation.

A multicentre follow-up of clinical aspects of traumatic spinal cord injury

STUDY DESIGN

Prospective, multicentred follow-up (FU) observational study.

OBJECTIVES

Prospectively evaluate survival, complications, re-admissions and maintenance of clinical outcome in people experiencing traumatic spinal cord injury (SCI).

SETTING

Seven spinal units and 17 rehabilitation centres participating in the previous GISEM (ie Italian Group for the Epidemiological Study of Spinal Cord Injuries) study.

METHOD

A total of 511 persons with SCI, discharged between 1997 and 1999 after their first hospitalisation, were enrolled. A standardised questionnaire was administered via telephone.

RESULTS

Of the 608 persons originally enrolled, 36 died between discharge and follow-up (mean 3.8+/-0.64 years). Of the remainder, 403 completed telephone interviews, 72 refused to participate and 97 could not be contacted. More than half of the patients interviewed (53.6%) experienced at least one SCI-related clinical problem in the 6 months preceding interview; the most frequent being urological complications (53.7%). At least one re-admission was recorded in 56.8% of patients between discharge and FU interview. Of the patients interviewed, 70.5% reported bowel autonomy and 86% bladder management autonomy. On multivariate analysis, lack of bowel/bladder autonomy was the most common variable with a strong predicting value for mortality, occurrence of complications and re-admissions.

CONCLUSION

Re-admission and major complications seem common after SCI and should be considered when planning facilities. Failure to obtain bowel/bladder autonomy upon discharge from rehabilitation proved to be the most common predictive factor of poor outcome during the period between discharge and FU interview.

Quality of life and aphasia. Multicentric standardization of a questionnaire

AIM

It is important to assess aphasics' quality of life in order to plan a rehabilitation treatment. To date such a tool is still missing for Italian patients. This paper reports normative data of the Italian version of SAQOL-39, a British questionnaire aimed to assess aphasics' quality of life. It consists of 39 items, divided into 4 subdomains (Physical, Communication, Psychosocial and Energy).

METHODS

Forty-two patients coming from 3 different Speech Therapy Services were enrolled. All patients completed speech therapy before examination. They were submitted to the Italian SAQOL-39 and 2 screening tests for aphasia: 1) Communication Assessment Scale according Goodglass and Kaplan; 2) Franchay Aphasia Screening Test (FAST). A receptive FAST score of 7 out of 15 was used as a cut-off score for SAQOL-39 administration.

RESULTS

The Italian SAQOL-39 showed good internal consistency (full scale Cronbach's alpha 0.939). Cronbach's alpha for every subdomains ranged from 0.950 (Communication) to 0.720 (Energy). Fluent aphasics gave significantly higher scores than nonfluent ones on full scale, and all out of Energy subdomains. Furthermore gravity of aphasia correlated with both full scale and Communication subdomain scores.

CONCLUSIONS

In authors' opinion, the Italian SAQOL-39 shares many psychometric features with the English one. This questionnaire seems to be suitable for clinical practice.

Follow-up in persons with traumatic spinal cord injury: questionnaire reliability

AIM. The aim of this study is to show the compliance and the test-retest reliability of the questionnaire.

METHODS

Construction of a structured questionnaire to perform a phone follow-up in 511 persons with traumatic spinal cord injury (SCI) 4 years after discharge from the first rehabilitative hospitalization. The questionnaire is structured in 24 items, comprising exclusion (closed questions) answers and 3 analogic scale answers, divided into 7 aspects: clinical conditions, sentimental relationships, quality of life, autonomy, mobility, occupation, social reintegration. A pilot survey on 20 subjects with SCI, hospitalized in different periods in 2 rehabilitation centers, was performed to check the questionnaire's feasibility and reproducibility. The persons were interviewed twice by telephone, with an interval of about one month, by a psychologist. The questionnaire was completed during one single phone conversation.

RESULTS

No missing answers were recorded. The test run for this questionnaire showed high reproducibility based on the large numbers of questions with 100% correspondence between the answers ''before'' and ''after''. For most of the other questions this factor ranged between 80% and 99%, and for 2 questions on the analogic scale between 30% and 50%.

CONCLUSIONS

The data collected by this pilot survey show the reliability of this questionnaire for all answers, save for the quantification of subjective variables.